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Quick GuideFor CliniciansBased on TIP 41Substance Abuse Treatment:Group TherapyGROUPTHERAPY

Quick Guide For Clinicians Based on TIP 41Substance AbuseTreatment: Group TherapyThis Quick Guide is based entirely on information contained inTIP 41, published in 2005, and based on information updatedthrough September 2004. No additional research has beenconducted to update this topic since publication of the TIP.

ContentsWhy a Quick Guide? . . . . . . . . . . . . . . . . . . . .2What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . . .3Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .4Groups Commonly Used in SubstanceAbuse Treatment . . . . . . . . . . . . . . . . . . . . . . .6Criteria for the Placement of Clients In Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Group Development andPhase-Specific Tasks . . . . . . . . . . . . . . . . . .29Group Leadership: Concepts and Techniques . . . . . . . . . . . . . . . . . . . . . . . . . .39Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

2 Substance Abuse Treatment: Group TherapyWHY A QUICK GUIDE?This Quick Guide was developed to accompanySubstance Abuse Treatment: Group Therapy,Number 41 in the Treatment ImprovementProtocol (TIP) series published by the Center forSubstance Abuse Treatment (CSAT), SubstanceAbuse and Mental Health Services Administration(SAMHSA). This Quick Guide is based entirely onTIP 41 and is designed to meet the needs of thebusy clinician for concise, easily accessed how-toinformation.The Guide is divided into eight sections (seeContents) to help readers quickly locate relevantmaterial. Terms related to group therapy are listedbeginning on page 50 in the Glossary.For more information on the topics in this QuickGuide, readers are referred to TIP 41.

What Is a TIP?3WHAT IS A TIP?The TIP series has been in production since 1991.This series provides the substance abuse treatmentand related fields with consensus-based,field-reviewed guidelines on substance abusetreatment topics of vital current interest.TIP 41, Substance Abuse Treatment: GroupTherapy• Presents an overview of the role and efficacy ofgroup therapy in substance abuse treatmentplanning• Offers recent research and clinical findings• Describes effective types of group therapy• Offers a theoretical basis for group therapy’seffectiveness in the treatment of substance usedisordersSee the inside back cover for information on howto order TIPs and other related products.

4 Substance Abuse Treatment: Group TherapyINTRODUCTIONGroup therapy can be a powerful therapeutic toolfor treating substance abuse. In many cases, it isas effective as individual therapy because groupsintrinsically have many rewarding traits, such asreducing isolation and enabling members to witnessthe recovery of others. These qualities candraw clients into a culture of recovery.Although many types of groups can have therapeuticelements and effects, the group therapymodels included in TIP 41 and this Quick Guideare appropriate for groups that (1) have trainedleaders and (2) are intended to produce sometype of healing or recovery from substance abuse.Advantages of Group TherapyThere are many advantages to using group therapyin substance abuse treatment. Groups can• Provide useful information to clients who arenew to recovery.• Allow a single treatment professional to help anumber of clients at the same time.• Provide positive peer support and pressure forabstinence from substances of abuse.

Introduction5• Help members learn to cope with problemsrelated to substance abuse by allowing them tosee how others deal with similar problems.• Provide feedback concerning the values andabilities of group members.• Help clients overcome past harmful familyexperiences.• Encourage, coach, support, and reinforce membersas they undertake difficult or anxietyprovokingtasks.• Offer members the opportunity to learn orrelearn the social skills they need to cope witheveryday life instead of resorting to substanceabuse.• Effectively confront individual members aboutsubstance abuse and other harmful behaviors.• Add needed structure and discipline to the livesof people with substance use disorders, whooften enter treatment with their lives in chaos.• Instill hope, a sense that “If they can make it,so can I.”• Support and provide encouragement to oneanother outside the group setting.

6 Substance Abuse Treatment: Group TherapyGROUPS COMMONLY USED INSUBSTANCE ABUSE TREATMENTSubstance abuse treatment professionals employa variety of group treatment forms, which TIP 41divides according to their model, type, or purpose.In the hands of a skilled leader, each form ofgroup treatment can provide powerful therapeuticexperiences for group members.Five Group Therapy ModelsTIP 41 describes five models of group therapy thatare effective for substance abuse treatment:• Psychoeducational Groups• Skills Development Groups• Cognitive–Behavioral/Problem-Solving Groups• Support Groups• Interpersonal Process Groups1. Psychoeducational GroupsPsychoeducational groups are designed to educateclients about substance abuse and relatedbehaviors and consequences. This type of grouppresents structured, group-specific content, oftentaught by means of videotapes, audiocassette, orlectures.Psychoeducational groups provide informationthat aims to have a direct application to clients’lives, such as instilling self-awareness, suggesting

Groups Commonly Used in Substance Abuse Treatment7options for growth and change, and promptingpeople using substances to take action on theirown behalf.Some of the contexts in which psychoeducationalgroups may be useful are• Helping clients in the precontemplative or contemplativestage of change to reframe theimpact of substance use on their lives, developan internal need to seek help, and discoveravenues for change. (For more information onthe stages of change, see TIP 35, EnhancingMotivation for Change in Substance AbuseTreatment.)• Helping clients in early recovery learn moreabout their disorders, recognize roadblocks torecovery, and deepen understanding of thepath they will follow toward recovery.• Helping families understand the behavior of aperson with a substance use disorder in a waythat allows them to support the individual inrecovery and learn about their own needs forchange.• Helping clients learn about other resources thatcan be helpful in recovery, such as meditation,relaxation training, anger management, spiritualdevelopment, and nutrition.

8 Substance Abuse Treatment: Group TherapyPrincipal characteristics. Psychoeducationalgroups generally teach clients that they need tolearn to identify, avoid, and eventually master thespecific internal states and external circumstancesassociated with substance abuse.Leadership skills and styles. Leaders in psychoeducationalgroups primarily assume the roles ofeducator and facilitator.Techniques. Techniques for conducting psychoeducationalgroups are concerned with (1) how informationis presented and (2) how to assist clientsto incorporate learning so that it leads to productivebehavior, improved thinking, and emotionalchange.2. Skills Development GroupsSkills development groups teach skills that helpclients maintain abstinence, such as• Refusal skills• Social skills• Communication skills• Anger management skills• Parenting skills• Money management skills

Groups Commonly Used in Substance Abuse Treatment9Principal characteristics. Because of the degree ofindividual variation in client needs, the particularskills taught to a client should depend on anassessment that takes into account individualcharacteristics, abilities, and background.Leadership skills and styles. In skills developmentgroups, as in psychoeducation, leaders need basicgroup therapy knowledge and skills, knowledge ofthe patterns that show how people relate to oneanother in groups, skills in fostering interactionamong members and managing conflict thatinevitably arises among members in a group environment,and helping clients take ownership forthe group.Techniques. The specific techniques used in askills development group will vary depending onthe skills being taught.3. Cognitive–Behavioral GroupsCognitive–behavioral groups are a well-establishedpart of the substance abuse treatment fieldand are particularly appropriate in early recovery.Cognitive processes include a number of differentpsychological activities, such as thoughts, beliefs,decisions, opinions, and assumptions. A numberof thoughts and beliefs are affected by an

10 Substance Abuse Treatment: Group Therapyindividual’s substance abuse and addiction. Somecommon errant beliefs of individuals enteringrecovery are• “I’m a failure.”• “I’m different.”• “I’m not strong enough to quit.”• “I’m unlovable.”• “I’m a (morally) bad person.”Principal characteristics. Cognitive–behavioraltherapy groups work to change learned behaviorby changing thinking patterns, beliefs, and perceptions.The group leader focuses on providing astructured environment within which group memberscan examine the behaviors, thoughts, andbeliefs that lead to their maladaptive behavior.For example, one model of a cognitive–behavioralgroup for individuals with posttraumatic stress disorder(PTSD) and substance abuse is designed to• Educate clients about the two disorders• Promote self-control skills to manage overwhelmingemotions• Teach functional behaviors that may have deterioratedas a result of the disorders• Provide relapse prevention trainingThe group format is an important element of themodel, given the importance of social support forPTSD and substance use disorders. In addition,

Groups Commonly Used in Substance Abuse Treatment 11group treatment is a relatively low-cost modality,so it can reach a larger number of clients.Leadership skills and styles. Some cognitive–behavioral approaches focus more on behavior,others on core beliefs, still others on developingproblem-solving capabilities. The level of interactionby the counselor in cognitive–behavioralgroups can vary from quite directive to relativelyinactive. Perhaps the most common leadershipstyle in such groups is active engagement and aconsistently directive orientation.Techniques. Specific techniques may vary by thespecific orientation of the leader but, in general,include the ability to (1) teach group membersabout self-destructive behavior and thinking thatleads to maladaptive behavior, (2) focus on problem-solvingand short- and long-term goal setting,and (3) help clients monitor feelings and behavior,particularly those associated with substance use.4. Support GroupsMany people with substance use disorders avoidtreatment because the treatment itself threatensto increase their anxiety. Support groups bolstermembers’ efforts to develop and strengthen theirability to manage their own thinking and emotionsand to develop better interpersonal skills as theyrecover from substance abuse.

12 Substance Abuse Treatment: Group TherapyPrincipal characteristics. The focus of supportgroups can range from strong leader-directed,problem-focused groups in early recovery, whichfocus on achieving abstinence and managing dayto-dayliving, to group-directed, emotionally andinterpersonally focused groups in middle and laterstages of recovery.Leadership skills and styles. Support group leadersneed a solid grounding in how groups growand evolve and the ways in which people interactand change in groups. The leader facilitates groupdiscussion and helps group members share theirexperiences and overcome difficult challenges.The counselor provides positive reinforcement forgroup members, models appropriate interactionsbetween individuals in the group, respects individualand group boundaries, and fosters open andhonest communication.Techniques. Counselor interventions in supportgroups are likely to be more interpretive andobservational and less directive than in manyother groups. The goal is not to provide insight togroup members, but to facilitate the evolution ofsupport within the group.

Groups Commonly Used in Substance Abuse Treatment 135. Interpersonal Process GroupsInterpersonal process groups use psychodynamics,or knowledge of the way people function psychologically,to promote change and healing. Alltherapists using a “process-oriented group therapy”model continually monitor three dynamics:• The psychological functioning of each groupmember (intrapsychic dynamics)• The way people are relating to one another inthe group setting (interpersonal dynamics)• How the group as a whole is functioning (groupas-a-wholedynamics)Principal characteristics. Interpersonal processgroup therapy delves into major developmentalissues, searching for patterns that contribute toaddiction or interfere with recovery.Leadership skills and styles. In interpersonalprocess groups, content is a secondary concern.Instead, leaders focus on the present, noticingsigns of people recreating their past in what isgoing on between and among members of thegroup.Techniques. In practice, group leaders may usedifferent models at various times and may simultaneouslyinfluence more than one focus level at atime.

14 Substance Abuse Treatment: Group TherapyThree variations of the interpersonal processgroup are• Individually focused groups. This group concentrateson individual members of the group andtheir distinctive internal cognitive and emotionalprocesses.• Interpersonally focused groups. In thesegroups, members evaluate each other’s behavior.The group leader monitors the way clientsrelate to one another, reinforces therapeuticgroup norms, and works to prevent contratherapeuticnorms.• Group-as-a-whole focused groups. In this group,the group leader focuses on the group as a singleentity or system.For more information on these group models, seeChapter 2 of TIP 41.Three Group Therapy TypesThere are three specialized types of groups thatdo not fit into the five model categories, but whichfunction as unique entities in the substanceabuse treatment field:• Relapse Prevention Groups• Communal and Culturally Specific Groups• Expressive Groups

Groups Commonly Used in Substance Abuse Treatment 151. Relapse Prevention GroupsRelapse prevention groups focus on helping aclient maintain abstinence or recover fromrelapse. This kind of group is appropriate forclients who have attained abstinence, but whohave not necessarily established a proven trackrecord indicating they have all the skills to maintaina drug-free state.Purpose. Relapse prevention groups help clientsmaintain their sobriety by providing them with theskills and knowledge to anticipate, identify, andmanage high-risk situations that can lead torelapse while also making security preparationsfor their future by striving for broader life balance.Principal characteristics. Relapse preventiongroups focus on activities, problem-solving, andskill building. They may also take the form of psychotherapy.Leadership skills and styles. Leaders of relapseprevention groups need to have a set of skills similarto those needed for a skills developmentgroup, along with a well-developed ability to workon group process issues.

16 Substance Abuse Treatment: Group TherapyGroup leaders need to be able to monitor clientparticipation to determine risk for relapse, to perceivesigns of environmental stress, and to knowwhen a client needs a particular intervention.Above all, when a group member does relapse,the leader should be able to help the groupprocess the event in a nonjudgmental, nonpunitiveway.Techniques. Relapse prevention groups draw upontechniques used in a variety of other types ofgroups, including the cognitive–behavioral, psychoeducational,skills development, and processorientedgroups.2. Communal and Culturally Specific GroupsCommunal and culturally specific wellness activitiesand groups include a wide range of activitiesthat use a specific culture’s healing practices andadjust therapy to cultural values. Such strengthsfocusedactivities can be integrated into a substanceabuse treatment program in several ways:• Culturally specific group wellness activities maybe used in a treatment program to help clientsheal from substance abuse and problemsrelated to it.• Culturally specific practices or concepts can beintegrated into a therapeutic group to instructclients or assist them in some aspect of recovery.For example, Hispanics/Latinos generally

Groups Commonly Used in Substance Abuse Treatment 17share a value of personalismo, a preference forperson-to-person contact. Alternately, a psychoeducationalgroup formed to help clientsdevelop a balance in their lives might use anAmerican Indian medicine wheel diagram.• Culturally or community-specific treatmentgroups may be developed within a services programor in a substance abuse treatment programserving a heterogeneous population witha significant minority population of a specifictype. Examples might include a group for peoplewith cognitive disabilities, or a bilingualgroup for recent immigrants.Purpose. Groups and practices that accentuatecultural affinity help curtail substance abuse byusing a particular culture’s healing practices andtapping into the healing power of a communal andcultural heritage.Principal characteristics. Different cultures havedeveloped their own views of what constitutes ahealthy and happy life. These ideas may provemore relevant to members of a minority culturethan do the values of the dominant culture, whichsometimes can alienate rather than heal.

18 Substance Abuse Treatment: Group TherapyLeadership characteristics and style. A groupleader for a culturally specific group will need tobe sensitive and creative. How much authorityleaders will exercise and how interactive they willbe depends on the values and practices of thecultural group. The group leader should pay attentionto a number of factors, all of which should beconsidered in any group but which will be particularlyimportant in culturally specific groups.Clinicians should• Be aware of cultural attitudes and resistancestoward groups.• Understand the dominant culture’s view of thecultural group or community and how thataffects members of the group.• Be able to validate and acknowledge past andcurrent oppression, with a goal of helping toempower group members.• Be aware of a cultural group’s collective griefand anger and how it can affect countertransferenceissues.• Focus on what is held in common among groupmembers, while being sensitive to differences.Techniques. Different cultures have specific activitiesthat can be used in a treatment setting. Somecommon elements in treatment include storytelling, rituals and religious practices, holiday celebrations,retreats, and rites of passage practices.

Groups Commonly Used in Substance Abuse Treatment 193. Expressive GroupsThis category includes a range of therapeuticactivities that allow clients to express feelings andthoughts–conscious or unconscious–that theymight have difficulty communicating with spokenwords alone.Purpose. Expressive therapy groups generally fostersocial interaction among group members asthey engage either together or independently in acreative activity.Principal characteristics. Expressive therapy mayuse art, music, drama, psychodrama, Gestalt,bioenergetics, psychomotor, games, dance, freemovement, or poetry.Leadership characteristics and style. Expressivegroup leaders will generally have a highly interactivestyle in group. They will need to focus thegroup’s attention on creative activities whileremaining mindful of group process issues.Techniques. The techniques used in expressivegroups depend on the type of expressive therapybeing conducted. Generally, these groups setclients to work on an activity, and client participationis a paramount goal if the therapy is to exertits full effect.

20 Substance Abuse Treatment: Group TherapyGroups Focused on a Specific PurposeIn addition to the five models of therapeuticgroups and three specialized types of groups discussedabove, groups can be classified by purpose.The purpose-focused group is a specificform of cognitive–behavioral therapy used to eliminateor modify a single problem, such as shyness,loss of a loved one, or substance abuse.Purpose. The primary purpose of a group focusedon a specific problem is to target, alter, and eliminatea group member’s self-destructive or selfdefeatingbehavior. Such groups are usually shorttermand historically have been used with addictivetypes of behavior (smoking, eating, substanceuse) as well as when the focus is on symptomreduction or behavioral rehearsal.Principal characteristics. Groups focused on a purposeare short (commonly 10 or 12 weeks), highlystructured groups of people who share a specificproblem. The group’s focus, for the most part, ison one symptom or behavior, and they use thecohesiveness among clients to increase the rateof treatment compliance and change. Thesegroups are particularly helpful for new clients;their focus helps to allay feelings of vulnerabilityand anxiety.

Groups Commonly Used in Substance Abuse Treatment 21Leadership characteristics and style. The groupleader usually is active and directive. Interactionwithin the group is limited typically to exchangesbetween the clients and the group leader; the restof the group acts to confront or support the clientaccording to the leader’s guidance.Techniques. In practice, group leaders may usedifferent models at various times, and may simultaneouslyinfluence more than one focus level at atime. For example, a group that focuses on changingthe individual will also have an impact on thegroup’s interpersonal relations and the group-as-awhole.Groups will, however, have a general orientationthat determines the focus the majority ofthe time. This focus is an entry point for the groupleader, helping to provide direction when workingwith the group.

22 Substance Abuse Treatment: Group TherapyCRITERIA FOR THE PLACEMENT OFCLIENTS IN GROUPSMatching Clients With GroupsThe success of a group therapy experience for theindividual can depend on appropriate placement.Before placing a client in a particular group, theprovider should consider• The client’s characteristics, needs, preferences,and stage of recovery• The program’s resources (e.g., should the programadministrator consider developingspecialty groups, such as a women-only group?)• The nature of the group or groups availableRecovery from substance abuse is an ongoingprocess and, if resources permit, treatment maycontinue in various forms for some time. Clientsmay need to move to different groups as theyprogress through treatment, encounter setbacks,and work to become committed to recovery.Assessing Client Readiness for GroupPlacement should begin with a thorough assessmentof the client’s ability to participate in a groupand the client’s needs and desires regardingtreatment.

Criteria for the Placement of Clients in Groups 23Not all clients are suited for all kinds of groups,nor is any group approach necessary or suitablefor all clients with a history of substance abuse.Clients who may be unsuited to group therapyinclude• People who refuse to participate• People who cannot honor group agreements• People in the throes of a life crisis• People who cannot control impulses• People whose defenses would clash with thedynamics of a group• People who experience severe internal discomfortin groupsPrimary Placement ConsiderationsA formal selection process is essential if cliniciansare to match clients with the groups best suited totheir needs and wants. For many groups, especiallyinterpersonal process groups, pre-group interviewsand client preparation are essential.After specifying the appropriate treatment level, atherapist meets with the client to identify optionsconsistent with this level of care. More specificscreens might be needed to determine whether,within the appropriate level of care, the client issuited to treatment in a group modality.

24 Substance Abuse Treatment: Group TherapyConsiderations include the following:• Women. Recent studies have shown that somewomen do better in same-sex groups than inmixed gender groups.• Adolescents. The complexities related to adolescentsand group therapy lie outside thescope of TIP 41. Suggested reading includesMotivational Enhancement Therapy andCognitive Behavioral Therapy for AdolescentCannabis Users: 5 Sessions (CSAT 2001),Group Therapy with Children and Adolescents(American Psychiatric Press 1996), andAdolescent Substance Abuse: Etiology,Treatment, and Prevention (Aspen Publishers1992).• Clients’ level of interpersonal functioning,including impulse control. Does the client posea threat to others? Is the client prepared toengage in the give-and-take of group dynamics?• Motivation to abstain. Clients with low levels ofmotivation to abstain generally should beplaced in psychoeducational groups.• Stability. In placement, both the client’s andgroup’s best interests need to be considered.• Expectation of success. Every effort should bemade to place the client in a group in which theclient (and, therefore, the group) can succeed.• Stage of recovery. For a summary of the typesof group treatment that are most appropriatefor clients at different stages of recovery, seethe Figures on the following page.

Criteria for the Placement of Clients in Groups 25

26 Substance Abuse Treatment: Group TherapyPlacing Clients From Racial or EthnicMinoritiesIn all aspects of group work for substance abusetreatment, clinicians need to be especially mindfulof diversity issues.Leader Self-AssessmentGroup leaders should be aware that their own ethnicitiesand standpoints can affect their interpretationof group members’ behavior. The groupleader brings to the group a sense of identity, aswell as feelings, assumptions, thoughts, and reactions.Leaders should be conscious of how theirbackgrounds affect their ability to work with particularpopulations.For a self-assessment guide for group counselorsworking with diverse populations, see Figure 3-9in TIP 41.Diversity and PlacementIn many groups, the members will be heterogeneous;for example, a majority of Caucasiansplaced with a minority of ethnically or racially differentmembers. The greater the mix of ethnicities,the more likely it will be that biases willemerge and require mediation.

Criteria for the Placement of Clients in Groups 27Before placing a client in a particular group, thetherapist needs to understand the influence ofculture, family structure, language, identityprocesses, health beliefs and attitudes, politicalissues, and the stigma associated with minoritystatus.To help ensure cohesion (a positive group qualitystemming from a sense of solidarity within thegroup), the group leader should• Inform the group members in advance that peoplefrom a variety of backgrounds, races, andethnicities will be in the group.• Model sensitivity and openness in order tocreate an atmosphere of tolerance.• Set the tone for an open discussion ofdifferences in beliefs and feelings.• Help clients adapt to and cope with prejudice ineffective ways, while maintaining theirself-esteem.• Integrate new clients into the group slowly,letting them set their own pace.• Encourage new members to participate.

28 Substance Abuse Treatment: Group TherapyWhen working with group members from differentcultural or ethnic backgrounds, a group leadershould consider the following:• Symbolism and nonverbal communication. Insome cultural groups, direct expression ofthoughts and feelings is consideredinappropriate.• Cultural transference. If a group member hashad experiences with people of the same ethnicityas the therapist, the group member maytransfer to the therapist the feelings and reactionsdeveloped with others of the therapist’sethnicity.• Cultural countertransference. Countertransferenceof culture occurs when a therapist’sresponse to a current group member is basedon a previous experience with a member of thesameethnicity.• Ethnic prejudice. In multiethnic groups, it isvital to develop an environment in which it issafe to talk about race. Not to do so may resultin division along racial lines.

Group Development and Phase-Specific Tasks 29GROUP DEVELOPMENT ANDPHASE-SPECIFIC TASKSGroup DevelopmentThe way groups are developed varies according tothe type of group. For the purpose of TIP 41 andthis Quick Guide, however, groups have been classifiedinto two broad categories, each with thesame two subcategories:• Fixed membership groups— Time-limited— Ongoing• Revolving membership groups— Time-limited— OngoingFixed Membership GroupsFixed membership groups generally have no morethan 15 members, and the membership is relativelystable. Typically, the therapist screensprospective members, and group membersreceive formal preparation for group participation.Any departure from the group occurs through awell-defined process. Two variations of this categoryare• A time-limited group, in which the same groupof people attend a specified number of sessions,generally starting and finishing together

30 Substance Abuse Treatment: Group Therapy• An ongoing group, in which new members canfill vacancies in a group that continues over along period of timeIn time-limited groups with fixed membership,learning in the group builds on what has happenedin prior meetings, so members need to bein the group from its start.In ongoing groups with fixed membership, the sizeof the group is set and new members enter onlywhen there is a vacancy.Revolving Membership GroupsNew members enter a revolving membershipgroup when they become ready for the service itprovides. Revolving membership groups are frequentlyfound in inpatient treatment programs.The two variations of revolving membershipgroups are• A time-limited group, which members generallyjoin for a set number of sessions• An ongoing group, which clients join until theyaccomplish their goalsRevolving membership groups can be larger thanfixed membership groups. They are generally morestructured and require more active leadership.In time-limited groups, each member is generallyexpected to attend a certain number of sessions

Group Development and Phase-Specific Tasks 31for a certain number of weeks or months. Examples of time-limited groups include psychoed­ucational groups, skills building groups, and psy­chodrama groups. Several possible varieties of ongoing groups have revolving membership. Such groups may be • Open-ended, with clients staying for as manysessions as they wish• A repeating set of topics, with clients stayingonly until they have completed all of the topics• A format that is not topic-specific, which clientsattend for a set number of weeks (either consecutivelyor nonconsecutively)Figure 4-1 in TIP 41 provides the characteristics offixed and revolving membership groups.Preparing for Client Participation in GroupsThe process of preparing the client for participationin group therapy begins as early as the initialcontact between the client and the program.Clients' preconceptions about the group, theirexpectation of how the group will benefit them,their understanding of how they are expected toparticipate, and whether they have experienced amotivational session prior to the group will allinfluence members' participation.

32 Substance Abuse Treatment: Group TherapyPre-group interviews are a widely used means ofgathering useful information about clients andpreparing them for what they can expect from agroup. Clients should be thoroughly informedabout what group therapy will be like. In addition,client preparation should• Explain how group interactions compare tothose in self-help groups, such as AlcoholicsAnonymous (AA).• Emphasize that treatment is a long-termprocess.• Let new members know that they may betempted to leave the group at times, but thatthey can gain a great deal from persistentcommitment to the process.• Give prospective and novice members anopportunity to express anxiety about groupwork, and help allay their fears withinformation.• Recognize and address clients’ therapeutichopes.In preparing prospective members for a groupexperience, it is important to be sensitive to peoplewho are different from the majority of theother participants in some way (e.g., much olderor younger than the rest, the lone woman, the onlymember with a particular disorder, or the only personfrom a distinctive ethnic or cultural minority).

Group Development and Phase-Specific Tasks 33The fixed membership format provides more timeto discuss issues of difference prior to joining agroup. A person who is unlike the rest of the groupmay be asked:• How do you think you would feel in a group inwhich you differ from other group members?• What would it be like to be in a group whereeveryone else is a strong believer in something,such as AA, and you are not?Such questions might be coupled with positivecomments that stress the benefits that a uniqueperspective may bring to the group.Increasing RetentionTo make it possible or easier for clients to attendregularly, retention rates in a group are positivelyaffected by• Client preparation• Maximum client involvement during the earlystages of treatment• The use of feedback• Prompts to encourage attendance• The provision of wraparound services (such aschild care and transportation)• The timing and length of the group

34 Substance Abuse Treatment: Group TherapyA number of pre-treatment techniques have beenshown to reduce incidence of dropout:• Role induction uses formats like interviews, lectures,and films to educate clients about thereasons for therapy, setting realistic goals fortherapy, expected client behaviors, and so on.• Vicarious pre-training via interviews, lectures,films, or other settings demonstrates whattakes place during therapy so that the clientcan experience the process without actuallycommitting to group membership.• Experiential pre-training uses group exercisesto teach the client behaviors such as self-disclosureand examination of emotions.• Motivational interviews use specific listeningand questioning strategies to help the clientovercome doubt about making changes.One effective way to retain clients can be used ingroups that have a few veteran members. Whennew members join, the old members are asked topredict which new member will be the first to dropout. This prediction paradoxically increases theprobability that it will not be fulfilled.Group AgreementsA group agreement establishes the expectationsthat group members have of each other, theleader, and the group itself.

Group Development and Phase-Specific Tasks 35A group member's acceptance of the agreementprior to entering a group has been described asthe single most important factor contributing tothe success of outpatient therapy groups. To reinforcethe importance of the agreement as thebasis for group activities, group members can beasked to recall specifics of the agreement duringthe first session.The agreement provides for a mutual understandingof the common task and the conditions underwhich it will be pursued. It is through the agreementthat the leader derives his or her authorityto work, to propose activities, and to confront amember to make interpretations.The group agreement is intended to inspire clientsto accept the basic rules and premises of thegroup and increase their determination and abilityto succeed. These agreements are not meant toprovide a basis for excluding or punishing anyone.Rather, violations can be useful material for groupmembers to discuss as part of the group process.When provisions of the group agreement are violated,the leader should ask questions that referinfractions to the group. For examples of grouptreatment stipulations, see Figures 4-4 and 4-5 inTIP 41.

36 Substance Abuse Treatment: Group TherapyThe following issues should be taken into considerationwhen developing a group agreement:• Communicating grounds for exclusion• Confidentiality• Physical contact• Use of mood altering substances• Contact outside the group• Participation in the life of the group• Financial responsibility• TerminationFor more detail regarding the elements of a groupagreement, see pages 70--75 of TIP 41.Phase-Specific Group TasksEvery group goes through three phases; a beginning,middle, and end. These phases occur at differenttimes for different types of groups. Thegroup leader is responsible for attending to certainkey elements at each of these points.Beginning Phase: Preparing the Group to BeginDuring the beginning phase of group therapy,issues arise around topics such as• Orientation• Beginners’ anxiety• The role of the leader

Group Development and Phase-Specific Tasks 37During the beginning phase• The purpose of the group is articulated.• Working conditions of the group areestablished.• A positive tone is set for the group.• Members are introduced.• The group agreement is reviewed.• A safe, cohesive environment is ensured.• Norms are established.• The work of the group begins.Middle Phase: Working Toward ProductiveChangeThe group in its middle phase encounters andaccomplishes most of the actual work of therapy.During this phase, the leader balances content(the information and feelings overtly expressed inthe group) and process (how members interact inthe group over time).Some ways in which a group leader can help thegroup accomplish its middle-phase tasks include• Opening the session• Tracking the process• Capitalizing on the energy of resistance• Connecting before tackling issues

38 Substance Abuse Treatment: Group Therapy• Encouraging mutual connections betweenmembers• Sharing the work• Closing the sessionFor more information on these tasks, see Figure4-6 in TIP 41.End Phase: Reaching ClosureTermination is a particularly important opportunityfor members to honor the work they have done,grieve the loss of associations and friendships,and look forward to a positive future.The group begins the work of termination whenthe group as a whole reaches its agreed-upon terminationpoint or a member determines that it istime to leave the group. In either case, terminationis a time for• Putting closure on the experience• Examining the impact of the group on eachperson• Acknowledging the feelings triggered bydeparture• Giving and receiving feedback about the groupexperience and each member’s role in it• Completing any unfinished business• Exploring ways to carry on the learning thegroup has offered

Group Leadership: Concepts and Techniques 39GROUP LEADERSHIP: CONCEPTS ANDTECHNIQUESSeveral desirable leadership traits and behaviors,along with specific concepts and techniques, canmake process groups successful. Leaders shouldknow how to• Convert conflict and resistance into positiveenergy that powers the group.• Manage disruptive group members, such asclients who talk incessantly or leave abruptly• Turn a crisis into an opportunity.Personal QualitiesThe personal qualities that an effective groupleader should have are• Constancy. The ability to promote an environmentwith small, infrequent changes can bevery helpful to a client in recovery.• Active listening. Strong listening skills are thekeystone of any effective therapy.• Firm identity. A firm sense of their own identities,together with clear reflection on experiencesin group, enables leaders to understandand manage their own emotional lives.

40 Substance Abuse Treatment: Group Therapy• Confidence. Leaders should be a model of theconsistency that comes from self-knowledgeand clarity of intent while remaining attentive toeach client’s experience. This secure groundingenables the leader to model stability for thegroup.• Spontaneity. Good leaders are creative andflexible.• Integrity. Leaders should be aware of ethicalissues that arise.• Trust. Group leaders should be able to trust others,and vice versa.• Humor. The therapist needs to be able to usehumor appropriately.• Empathy. The ability to project empathy is anessential skill for the counselor.For more information on these personal qualities,see pages 93--95 of TIP 41.Leading GroupsGroup therapy with clients who have histories ofsubstance abuse or addiction requires active,responsive leaders who keep the group lively andensure that members are continuously and meaningfullyengaged with each other. The followingbehaviors and abilities are important when leadinggroups:• Leaders are able to vary therapeutic stylesbased on the needs of clients.

Group Leadership: Concepts and Techniques 41• Leaders model behavior.• Leaders can be co-therapists.• Leaders are sensitive to ethical issues.• Leaders are able to work within professionallimitations.• Leaders are flexible.• Leaders avoid role conflict.• Leaders improve motivation and overcomeresistance.• Leaders defend limits and group agreements.• Leaders maintain a safe therapeutic setting.• Leaders encourage communication withinthe group.For more information on these issues, see pages96--106 of TIP 41.InterventionsInterventions may be directed to an individual orthe group as a whole. A well-timed, appropriateintervention has the power to help clients• Recognize blocks to connection with otherpeople• Discover connections between the use of substancesand inner thoughts and feelings• Understand attempts to regulate feeling statesand relationships• Build coping skills

42 Substance Abuse Treatment: Group Therapy• Perceive the effect of substance abuse ontheir lives• Notice meaningful inconsistencies amongthoughts, feelings, and behavior• Perceive discrepancies between stated goalsand what is actually being doneManagement of the GroupHandling ConflictConflict in group therapy is normal, healthy, andunavoidable. When it occurs, the therapist’s taskis to make the most of it as a learning opportunity.Conflict can present opportunities for group membersto find meaningful connections with eachother and within their own lives. In many cases,the observation that a conflict exists and that thegroup needs to pay attention to it actually makesgroup members feel safer.The therapist is not responsible, however, forresolving conflicts. Once the conflict is observed,the decision to explore it further is made basedon whether such inquiry would be productive forthe group as a whole.

Group Leadership: Concepts and Techniques 43Subgroup ManagementIn any group, subgroups inevitably will form. Onekey role for the therapist in such cases is to makecovert alliances overt. The therapist can involvethe group in identifying subgroups by saying, “Inotice Jill and Mike are finding they have a gooddeal in common. Who else is in Jill and Mike’ssubgroup?”Subgroups can sometimes provoke anxiety, especiallywhen a therapy group is made up of peoplewho were acquainted before becoming groupmembers. Group members may have used drugstogether, slept together, worked together, or experiencedresidential substance abuse treatmenttogether. Obviously, such connections are potentiallydisruptive, so when groups are formed, groupleaders should consider whether subgroups wouldexist.When subgroups stymie full participation in thegroup, the therapist may be able to reframe whatthe subgroup is doing. At other times, a change inthe room arrangement may reconfigure undesirablecombinations.

44 Substance Abuse Treatment: Group TherapyResponding to Disruptive BehaviorClients who cannot stop talking. When a clienttalks on and on, he or she may not know what isexpected in a therapy group. The group leadermight ask, “Bob, what are you hoping the groupwill learn from what you have been sharing?” IfBob's answer is, “Well, nothing really,” it might betime to ask more experienced group members togive Bob a sense of how the group works.If group members exhibit no interest in stopping aperpetually filibustering client, it may be appropriateto examine this silent cooperation, as well.The group may be all too willing to allow the talkerto ramble on in order to avoid examining their ownpast. When this motive is suspected, the leadershould explore what group members have andhave not done to signal the speaker that it is timeto yield the floor.Clients who interrupt. Interruptions disrupt theflow of discussion in the group, with frustratingresults. The client who interrupts is often someonenew to the group and not yet accustomed toits norms and rhythms. The leader may invite thegroup to comment on the interruption as a form ofintervention.

Group Leadership: Concepts and Techniques 45Clients who flee a session. Clients who run out ofa session often are acting on an impulse thatothers share. It would be productive in suchinstances to discuss these feelings with the groupand to determine what members can do to talkabout these feelings when they arise.Other Common ProblemsComing late or missing sessions. Sometimes,addiction counselors view a client who comes togroup late as a person who is behaving ‘badly.’ Itis more productive to see this kind of boundaryviolation as a message to be deciphered.Sometimes this attempt will fail, however, and theclinician may decide the behavior interferes withthe group work too much to be tolerated.Silence. A group member who is silent is conveyinga message as clearly as one who speaks.Silent messages should be heard and understood,since nonresponsiveness may provide clues to aclient’s difficulties in connecting with his or herown inner life or with others.

46 Substance Abuse Treatment: Group TherapySpecial consideration is sometimes necessary forclients who speak English as a second language.Such clients may be silent, or respond only after adelay, because they need time to translate whathas just been said into their first language.Tuning out. When a group member seems presentin body but not in mind, it helps to tune into themjust as they are tuning out. The leader shouldexplore what was happening as an individualbecame inattentive. Perhaps the person wasescaping from difficult material or was havingmore general difficulties connecting with otherpeople. It may be helpful to involve the group ingiving feedback to clients whose attention falters.It also is possible, however, that the group as awhole is sidestepping matters that have to do withconnectedness. The member who tunes out mightbe carrying this message for the group.Participating only around the issues of others.Even when group members are disclosing littleabout themselves, they may be gaining a greatdeal from the group experience, remainingengaged around issues that others bring up.

Group Leadership: Concepts and Techniques 47To encourage a member to share more, a leadermight introduce the topic of how well membersknow each other and how well they want to beknown.Fear of losing control. Sometimes clients avoidopening up because they are afraid they mightbreak down in front of others, a fear particularlycommon in the initial phases of groups. When thisrestraint becomes a barrier to clients feeling acutepain, the therapist should help them rememberways that they have handled strong feelings in thepast.When a client’s fears of breaking down or becomingunable to function may be founded in reality(e.g., when a client has recently been hospitalized),the therapist should validate the feelings offear, and should concentrate on the strength ofthe person’s adaptive abilities.

48 Substance Abuse Treatment: Group TherapyFragile clients with psychological emergencies.Some clients wait until the last few minutes ofgroup to share emotionally charged information. Itis important for the leader to recognize that theclient may have deliberately chosen this time toshare this information. The timing is the client’sway of limiting the group’s responses and avoidingan onslaught of interest. The group members orleader should point out this self-defeating behaviorand encourage the client to change it.Anxiety and resistance after self-disclosure.Clients may feel great anxiety after disclosingsomething important, such as the fact that theyare gay or victims of sexual abuse. Often, theywonder about two possibilities: “Does this meanthat I have to keep talking about it? Does thismean that if new people come into the group, Ihave to tell them, too?”To the first question, the therapist can respondwith the assurance, “People disclose in here whenthey are ready.” To the second, the member whohas made the disclosure can be assured of nothaving to reiterate the disclosure when newclients enter. Further, the disclosing member isnow at a different stage of development, so thegroup leader could say, “Perhaps the fact that youhave opened up the secret a little bit suggeststhat you are not feeling that it is so important to

Group Leadership: Concepts and Techniques 49hide it any more. My guess is that this, itself, willhave some bearing on how you conduct yourselfwith new members who come into the group.”For more information on group managementissues, see pages 116--122 of TIP 41.

50 Substance Abuse Treatment: Group TherapyGLOSSARYCohesion: A positive quality of groups denoting asense of enthusiastic solidarity within the group.Communal and Culturally Specific Groups:Groups formed in order to use the sense ofbelonging to a culture to reduce or eliminate substanceabuse and other negative behaviors.Conflict: A basic dynamic in groups in whichmembers have opposing views, beliefs, oremotions.Content: Information and feelings expressed ingroup; its complement is process.Expressive Groups: Groups formed to use somekind of creative activity (i.e., painting, dance, psychodrama)to help clients explore their substanceabuse, its origins and effects, and new copingoptions.Fixed Membership Groups: Relatively smallgroups with a set number of members who staytogether over a long period of time; people intime-limited fixed membership groups start andstay together, while ongoing fixed membershipgroups bring in new members if a vacancy occurs.

Glossary 51Group Agreement: A contract between providerand client stipulating the responsibilities of clientsand their expectations of other group members,the leader, and the group.Group Dynamics: Forces at work among smallgroups of interacting people; collectively, groupdynamics are a complex amalgam of individualpersonalities and actions combined with the overarchingproperties of the group as a whole.Group Process: How events take place in group,in contrast to content, which is what takes place;if, for example, a question is raised, a process-orientedgroup leader might silently note circumstancessuch as voice quality, facial expression,what came before and after the question, andhow the question was directed (to the leader? thegroup? to an individual? away from someone?).Heterogeneous Groups: Groups made up of amixture of clients.Homogeneous Groups: Groups made up of clientswho are alike in some respect other than a commonsubstance use problem (i.e., all women, allelderly, or all from a specific culture).

52 Substance Abuse Treatment: Group TherapyInterpersonal Process Groups: Formed to usegroup interactions to promote change and healing.Such groups are used after abstinence is wellestablished; they delve into major developmentalissues that contribute to addiction and interferewith recovery. Interpersonal process groups attendmore to process and less to content.Interpersonal Relationship Dynamics: How peoplerelate to one another in group settings andhow one individual can influence the behavior ofothers in group, such as by giving and receivingfeedback from each other.Intrapsychic: Relating to events occurring withinthe psyche, mind, or personality; that is, internallywithout reference to any external factors.Problem-Focused Groups: Groups formed toaddress a particular problem that contributes tosubstance abuse or limits recovery options; problem-focusedgroups also look at the process ofproblem-solving so members can generalize theirexperience in group to other life areas.Process: How members interact in the group; itscomplement is content.

Glossary 53Process-Oriented Therapy: An approach to grouptherapy that emphasizes group interaction as thehealing agent; the role of the leader is to promoteof interaction among group members.Psychodynamic Therapy (or Approach): Anapproach to psychological growth and change thatemphasizes the evolution and adaptation of thepsychological structure within an individual.Psychodynamic therapy often focuses on changingbehavior in the present by re-examining and revisinga person’s understandings and reactions toevents in the past.Revolving Membership Groups: Somewhat largerthan fixed membership groups, revolving membershipgroups acquire new members when theybecome ready for its services; time-limited revolvingmembership groups keep a member for aspecified period of time, while ongoing revolvingmembership groups may have clients who (1) stayas long as they wish, (2) enter a group with arepeating cycle of topics and stay until they havecompleted all the topics, or (3) attend for a settime (either consecutively or non-consecutively).

54 Substance Abuse Treatment: Group TherapySkills Development Groups: Groups formed tobring about or improve the skills needed toachieve and maintain abstinence; such skills mayrelate directly to substance abuse, or they may bedesigned to reduce or eliminate general life problemsthat imperil recovery.Stages (or Phases) of Group Development: In thebeginning phase, the group is prepared to beginits work. The middle phase, or actual work of thegroup, is the time for here-and-now interactionsthat help clients rethink behaviors and undertakechanges. The end phase is a mixture of recognitionand celebration of work done and goalsachieved, mourning for the loss of the attachmentsformed in group, and reorientation towardthe future.

Ordering InformationTIP 41Substance Abuse Treatment:Group TherapyTIP 41-RELATED PRODUCTSTraining ManualDo not reproduce or distribute this publication for a fee withoutspecific, written authorization from the Office ofCommunications, Substance Abuse and Mental Health ServicesAdministration, U.S. Department of Health and Human Services.Three Ways to Obtain FREE Copiesof All TIPs Products:1. Call SAMHSA’s Health Information Network at1–877–726–4727 (English and Español).2. Visit NCADI’s Web site at:http://www.ncadi.samhsa.gov.3. You can also access TIPs online at:http://www.kap.samhsa.gov.

Other Treatment ImprovementProtocols (TIPs) that are relevant tothis Quick Guide:TIP 34: Brief Interventions and Brief Therapies forSubstance Abuse SMA 07-3952TIP 35: Enhancing Motivation for Change inSubstance Abuse Treatment SMA 08-4212TIP 39: Substance Abuse Treatment and FamilyTherapy SMA 08-4219Improving Cultural Competence in SubstanceAbuse Treatment (Expected publication date2009)Substance Abuse Treatment and Trauma(Expected publication date 2009)See the inside back cover for ordering information for allTIPs and related products.HHS Publication No. (SMA) 09-4024Printed 2005Reprinted 2009